Provider Demographics
NPI:1699296947
Name:LACKNETT, JENNIFER ODESSA (MSW,LSW,LCDC III)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ODESSA
Last Name:LACKNETT
Suffix:
Gender:F
Credentials:MSW,LSW,LCDC III
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ODESSA
Other - Last Name:LAUVRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW,LSW,LCDC III
Mailing Address - Street 1:5559 RAIDERS ROAD
Mailing Address - Street 2:
Mailing Address - City:FRAZEYBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 S 4TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5002
Practice Address - Country:US
Practice Address - Phone:614-334-6903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2024-03-17
Deactivation Date:2018-03-19
Deactivation Code:
Reactivation Date:2021-08-17
Provider Licenses
StateLicense IDTaxonomies
OHS.2004927101YM0800X
OHLICDC.162436101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty